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The Role of the Specialist Nurse Practitioner in Facilitating Learning
Specialist nursing, a multi faceted discipline, has a plethora of duties, one of which, the role of learning facilitator, a demanding and complex role, requires thoughtfulness and reflection. Careful planning is required to engage the nurse in the learning process and equip him/ her with skills necessary for the clinical setting. Anxiety associated with nursing students' education and clinical experiences has been documented (Admi, 1997). The Specialist Nurse Practitioner must make every effort to facilitate a rewarding learning experience which will also impact positively on patient care.
Comparing and Contrasting Theories of Teaching and Learning:
The range of teaching and learning theories is as diverse as it is complex. While the aim is always to enable learners to improve upon their practice, and therefore improve standards of patient care, ways of doing this vary widely. There has been a theoretical shift from teacher-centred to student-centred models of teaching and learning, particularly in recent years, with a greater emphasis on collaborative, interactive student learning. This mirrors a shift in the way learning is viewed. Once thought of as a passive process – something done to the learner over which he/she has little or no control – the behaviourist viewpoint, most clearly associated with the transmission model of teaching, it is now though of largely as an active process, most effective when the learners are fully engaged in an interactive teaching and learning approach, the focus of the student-centred development models of teaching. By comparing and contrasting relevant theories the most suitable approach will be selected for the following teaching activity:
MANAGEMENT OF THE PATIENT WITH TUMOUR RELATED DYSPHAGIA
Patients Undergoing S.E.M.S.
Aims for Learning:
The potential for learning in practice settings is extraordinary (Thompson, 2004, page 1). Continuing Professional Development within nursing is essential for maintaining high standards of patient care, disseminating good practice methods and developing a learning and teaching culture.
The Dearing Report on Higher Education (National Committee of Inquiry into Higher Education, 1997) highlighted the importance of 'lifelong learning'. For lifelong learning to be effective the learner needs to work towards achieving some skills and competencies (Hinchliff et al., 2004, p.51). The aims in this example will be to foster in learners an understanding of oesophageal cancers, patient management issues, treatments and empathy with patients.
Aims of Teaching:
Working Together-Learning Together (DoH, 2001) discusses the constant development and updating of skills in which all professionals must engage. It is incumbent, therefore, upon the Specialist Nurse Practitioner to develop the appropriate degree of specialist knowledge with which to do this.
Definition of Learning:
The many definitions of learning generally agreed that 'learning is a relatively persistent change in an individual's behaviour due to experience.' (Fontana, 1995, page141).
These are based on the idea of stimulus and response leading to conditioning. The teacher provides a stimulus to which a student responds, implying that learning is a passive process beyond the learner's control. The teacher conditions the student's response.
There are two types of conditioning:
- Classical Conditioning – mainly the work of the psychologist Pavlov. He observed what he called an unconditioned response in dogs. They salivated at the sight of food, an innate tendency. He trained the dogs to salivate at the sound of a bell that indicated that food was imminent. Pavlov called this a conditioned response.
Pavlov's work has been criticised (Curzon, 1997, p. 39) as it pertains to animals who behave differently from humans.
- Operant Conditioning – most clearly demonstrated in the work of B.F. Skinner (1904-1900). Skinner identified learning as having three distinct stages:
- The stimulus with which the learner is confronted (S)
- The behaviour which this stimulus elicits from the learner (B)
- The reinforcement which follows this behaviour (R )
Favourable results for the learner, known as positive reinforcement, increase the likelihood of the behaviour happening at some time in the future. Unfavourable results, known as negative reinforcement, decrease the likelihood of the behaviour occurring in the future (Skinner 1972).
The effectiveness of this approach for teaching practitioners has been questioned (Howard, 2004, p.64). The Behaviourist approach does, however, remain a strongly held view, for it seems self-evident that a great deal of learning is initiated by external stimuli which call for responses, and that society confirms or denies the validity of those responses. (Rogers, 2002 p.89).
Some behaviourist ideas underpin other learning theories. The stimulus and response idea is contained in other theories in different forms. The stimulus can be regarded as material provided by the teacher with the reward being teacher feedback. For success with this approach, teachers must present material in a stimulating manner and give positive feedback to students.
Constructivism can be traced back to the work of the Immanuel Kant, the Enlightenment philosopher. In 'Critique of Pure Reason' (Kant, 1929) he argued that meaningful experiences which we would today regard as learning come about as the result of an interaction between the world and the mind. He challenged the view of the time that learning is a passive process over which the learner has no control.
The constructive approach advocates learning as an active process, occurring only when new experiences build on and develop previous ones. Constructivism is gaining favour in many parts of the world and in many disciplines (Young & Maxwell, 2006, p.8), with an implication that there should be a shift in focus from the content of learning to the nature of the learning process. The learning environment is designed to challenge previous ideas and develop a deeper conceptual understanding with an emphasis on the learner having a rationale for learning.
Almost two centuries after him, Jean Piaget developed Kant's constructivist approach. Kant believed that children knew less than adults simply because of less experience of the world. Piaget disagreed and demonstrated, through extensive research, that cognitive ability follows a series of developmental stages. He showed that the conceptual tools which we use to come to understand the world, develop in early childhood through interaction with problems, rather than being fixed at birth (Piaget, 1970). What we know as Constructivism, Piaget called as 'genetic epistemology'. Piaget's work led to a distinction between rote learning and interactive learning.
The idea that classroom learning could be improved using a more interactive approach had been proposed by the educational theorist John Dewey. His problem- based learning approach included many of the ideas central to Constructivism. He proposed that presenting students with problems meaningful to them in terms of their own life experiences would foster the development of creative intelligence (Dewey, 1938).
Dewey and Piaget both recognised that human beings tend to be uncomfortable with contradictions and inconsistencies in knowledge structures and will seek resolution. Piaget believed that the development of knowledge lay in this desire which came about through a process he called "equilibration". It consists of two distinct parts - assimilation and accommodation.
For Piaget assimilation involves making sense of new information within the parameters of existing knowledge, for example, an understanding of the concept "oak" can be developed out of an existing understanding of the concept of "tree". Accommodation is the processes of modifying behaviour in order to accommodate the inconsistent information, for example, a realisation that one cannot change the properties of water. From Piaget's perspective the educator must create an atmosphere that will challenge existing concepts, thus triggering the equilibration process.
Piaget's work has been criticised for regarding learning as individualistic, with little or no social dimension. This criticism led to the Social Constructivist model pioneered largely by Leo Vygotsky. Like Piaget, Vygotsky made extensive use of research in developing his theory but they differed in their views about how knowledge is developed. While Piaget concluded that knowledge was constructed through individual interaction with the world, Vygotsky believed that learning and the construction of knowledge associated with it was primarily a social enterprise.
Vygotsy used the terms "intermental" and "intramental" abilities. Intermental refers to functions performed by an individual in a social setting, while intramental refers to functions that one performs independently. He argued that all ability has to be mastered at the social intermental level before being developed at the intramental level.
The cooperative learning approach draws heavily on Vygotsky's theories. The underlying idea is that when students work collaboratively, they are able to draw on problem solving capacities that they would be unable to invoke if working independently (Young & Maxwell, 2006, p15-16).
Cognitive theories, which are student-centred, draw to some degree on the Behaviourist ideas of stimulus and response but the response is viewed as being formed by the learner. The underlying idea is that intelligence is the capability for learning which will continue to develop if it is constantly used. A major contributor to this area was Jerome Bruner. He argued that learning was an active process whereby individuals took incoming information and used it. Like Piaget, Bruner identified stages in the learning process but whereas Piaget believed that these happened in a sequential way, each following on from the previous one, Bruner believed that we use all of these throughout life as situations demand.
From the cognitive viewpoint learning can only occur through understanding which can only happen when material is broken into manageable chunks. Through an incremental process, skills become more complex. The learner is seen as active but this activity is controlled by the teacher who manages the knowledge.
These emerged as a reaction against the linear theories of learning. They relied on the distribution of personality traits along a continuum, for example, the introversion-extroversion scale, and purported that learning depends on self-perception as opposed to one's perception of the subject matter. Rogers proposed the concept of 'learning maps' whereby individuals draw maps of themselves and place all their activities, concepts and experiences on the map. Learning, it is suggested, is easiest among the subjects closest to the self-centre; and this implies that teaching involves a process of helping each participant re-draw their personal map so as to bring the subject closer to the self-centre (Rogers, 2002, p92).
The humanist approach asserts learner's engagement with the learning process, emphasising the learner's drive towards the fulfilment of self-set goals. Motivation to learn is seen as inherent to the human condition, driven from within. Material used for learning is seen as less important than the learner's goals and the teacher's role is to widen the learner's experience to facilitate the achievement of these goals.
This theory, first put forward by Dewey in his book 'Experience and Education' in 1938, suggests that learning is based on experience. There has since been general agreement that the experiences we have lead us into learning (Rogers, 2002, p.94). Concepts such as 'difficult' are seen as being relative to the learner, embedded in personal experiences. What one learner regards as difficult, another may find relatively easy, an idea which undermines the linear progression proposed in other theories. It has been applied in the clinical nursing education setting. Reflecting the learner's personal perception and understanding of a situation, it can develop moral, professional and personal understanding (Thompson, 2004, p.13).
A perspective on teaching is a lens through which we view our work as educators (Pratt & Paterson, 2006, p.59). Perspective is something of which the educator may not always be consciously aware but involves interaction with the whole learning process and the way learning is facilitated.
This has been employed for many years to teach adults in many settings including nursing education. The main premise is that the teacher has sufficient specialist subject knowledge to deliver content effectively. The Specialist Nurse Practitioner's main responsibility is to demonstrate professional skill and dispense professional knowledge accurately and efficiently (Pratt & Paterson, 2006, p.59). This approach has little effect in actively engaging the learner. Its success is dependent on teacher effectiveness and, in particular, the enthusiasm with which the material is presented, something over which the student has no control, the Behaviourist idea of passive learning. The transmission model has been heavily criticised because of the idea that learning is completely independent of previous experience. Previous knowledge and the ability to deal with present content are assumed. Constructivists argue that learning cannot occur independently of previous experience. The transmission model has been discredited in much of nursing education, especially in clinical and community practice settings (Pratt & Paterson, 2006, p. 59-61).
Student-centred approaches to teaching are embedded in constructivist ideology. The focus moves away from the idea of a passive student towards the idea of interactive student learning. Effective teaching is planned with the learners in mind and necessitates the learning facilitator having an understanding of the range of abilities and previous experiences of learners. Knowledge of the student group is particularly important when delivering emotive ideas, particularly to the novice, and must be carefully planned for. It is a good idea to ascertain a baseline for the student group from which to work. This can be done using data collection methods such as questionnaires or surveys or simply having a conversation. Effective teachers must understand their learners' prior understanding of the content, entry levels of skill and attitudinal predispositions (Pratt & Paterson, 2006, p.61).
Adopting a teaching Method:
The aim of teaching is to facilitate learning which will lead to an improvement in patient care. A review of the literature and the preceding discussion indicates that an approach based in constructivist ideology, with the learner central to the process, will be most effective. Learning begins with students' experiences, the platform on which knowledge, understanding, skills and competencies for professional practice are built. Nurse educators who practice in this way not only prepare students with the knowledge necessary for competent practice but also create an environment in which students learn to think critically, practice reflectively, work effectively in groups and access and use new information to support their practice, while modelling respect for meanings of lived experiences, learning and collaborative processes (Johns, 2002).
Planning For Teaching:
Cropley (1981) (cited in Hitchliff et al., 2004, p.51) proposed a framework for successful lifelong learning:
- An ability to set and work towards realistic goals that are achievable within the individual's personal and professional life: For the Specialist Nurse Practitioner this involves giving students the skills with which to manage their learning and to develop the ability to set achievable goals for themselves.
- Effective application of theory in practice to tackle work-based problems and an ability to measure the results: in the context of the present teaching example this may include enabling the learners to develop new approaches to patient diet sheets and Stent patient information sheets.
- Maintaining motivation to learn continuously and an ability to evaluate the effectiveness of this learning: This can be achieved through a professional approach to delivery, with clear learning intentions and an appropriate balance of theory with practice. Learners need opportunities to employ their new knowledge and skills in the practical setting. It is only through this experience that the learning becomes meaningful.
- Familiarity with a variety of learning and assessment strategies in a range of settings: assessment at the end of this particular teaching session may take the form of discussion and student feedback. This is extremely important for the Specialist Nurse Practitioner as it enables reflection and forms the basis for planning the next session.
- An ability to locate relevant information and resources, using appropriate media. Learners need this ability in order to develop their own learning.
In this teaching example, as with all effective teaching, it is essential to make explicit to students from the outset the learning intentions, the processes through which these are going to be met and the success criteria by which this will be measured.
These give a rationale for the learning, enable learners to set goals for themselves and, at the end of the teaching session, enable them to reflect on and evaluate their learning.
For this teaching session the learning intentions will be the following:
By the end of the session students will:
- Have a clear understanding of the background to oesophageal cancer.
- Be able to discuss treatments pertaining to oesophageal cancer, with particular emphasis on S.E.M.S. (self expanding metal stents).
- Have an understanding of the best way to manage patients with S.E.M.S..
- Have the ability to develop an empathy with the patient group.
Delivering the Lesson:
The mode of delivery for the teaching session is a visual presentation. At each stage in the dissemination of information the Specialist Nurse Practitioner should actively engage students in the learning process by:
- The use of effective and appropriate questioning which challenge previous views and develops the thinking process. This is central to the achievement of the learning intentions as it challenges students to think about their learning and their thinking processes as well as the content under discussion. Patients' case histories can be used to elicit meaningful discussion.
- Assisting the students in bridging the gap between what they know and what they are learning, an important aspect of the constructivist approach. This can be done in the form of stories, metaphors, patient case studies or other material which will be meaningful to the group. In this way the learners can link new knowledge to their previous knowledge and develop new, more complex, and sophisticated forms of reasoning and problem solving (Pratt & Paterson, 2006, p.62).
Develop effective questioning and thinking skills on the part of the learners through the use of scenarios, for example:
- What would you do if a patient presented with these symptoms?
- How would you react in a particular situation?
- How would you advise a patient in respect of after care?
These are useful strategies for developing understanding and ability to apply professional knowledge to situations as they arise. While the idea of challenge may be new to some, it is central to the learning process and can be developed over time through appropriate behaviour on the part of the Specialist Nurse Practitioner.
- Learners should be given opportunities for collaborative learning through discussion, brainstorming and other types of shared work with their peers.
Assessing the learning:
An effective learning facilitator will have integrated research into the teaching to give meaning to the learning aims. This may be in respect of incident, diagnosis, and prognosis and so on. At the end of the session both the learners and the teacher need to have some form of assessment. The process of refection enhances the learning for the learners and enables the Specialist Nurse Practitioner to develop his/her skills. Assessment of the teaching session is a measure of how well the students have met the success criteria and attained the learning intentions. Assessment may be informal, gauged through discussion or student feedback, or it may be formal, the information elicited from a follow-up activity or task. It also forms to focus for the Specialist Nurse Practitioner for the next stage of the teaching programme.
Developing and sustaining student motivation to learn is an important part of the teaching process. Motivation is seen as being dependent on many factors intrinsic or extrinsic to individuals. It has been argued that motivation can be learned but exactly what the factors are that lead to motivation being learned are not clear (Rogers, 2002 p.98). Ewan and White (1996) argue that intrinsic and extrinsic motivators are rarely mutually exclusive - the intrinsic motivation with which many nurses enter the profession can be overtaken by an extrinsic need to pass exams.
Effective communication will have an effect on learning. Communication is an essential part of professionalism in nursing (Ustun, 2006). The learning facilitator must communicate effectively with students and enable them to develop their communication skills in order to enhance clinical practice. This is particularly important for patient care. One of the aspects of management in the teaching session under discussion is the psychological aspect, such as empathising with the patient and ensuring that the patient understands the processes and procedures.
Thompson has identified five important aspects for the communication process to be effective:
- Listening and Responding effectively.
- Helping the student to identify feelings and personal knowledge.
- Sharing yourself and your intuitive practice as well as thoughts and feelings.
- Being sensitive to the student's needs.
- Being aware of your personal strengths and weaknesses and their effects upon others.
(Thompson, 2004, p.17).
Nurse educators are reflective of the general shift that has occurred in nursing in recent years – the move from nurse-centred activity to client-centred practice (Young & Maxwell, 2006, p.19). Constructivist models of education support this shift with the transition from a passive to an active process of learning. In a 2004 survey of nurses in advanced specialist roles, these nurses reported spending 17% of their time in education. One aspect of job satisfaction named was the opportunity to disseminate good practice and they viewed suitable educational preparation as vital to their role (RCN, 2005). With this in mind, the challenge facing the Specialist Nurse Practitioner is to facilitate learning through a student-centred approach. Student-Centred teaching derives from the same principles as client-centred nursing (Young et.al, 2006, p.28) and is important for developing skills in a rapidly changing and demanding environment.
Nursing education has seen a move from a transmission model for teaching to a student-centred one and the many challenges that come with this. An active approach does not have to mean a move away from lectures or this mode of delivery. The challenge facing Specialist Nurse Practitioners as nursing moves forward is to develop interactive teaching methods to actively engage learners so that standards continue to rise. It is important to remember that one of the aims of the learning facilitator is to provide a framework for Continued Professional Development for the professional engaged in the learning (Unsworth, 2004, p.51).
Diekelmann has argued that nurses have not been given enough of an input into the learning process (Diekelmann, 2002). Students are more likely to become engaged in their own learning when they are involved in creating their own educational experiences (Brown & Rodney, 2006, p.143). It is essential therefore to engage learners in discussion about their learning needs so that the Specialist Nurse Practitioner can develop his/her role of learning facilitator.
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